Skin Tears. Prevention, assessment and management

Skin Tears Prevention, assessment and management Workbook to record your training and personal development in prevention, assessment and management of skin tears Version 2

2 NHS Education for Scotland 2015. You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial education purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.

Skin Tears Prevention, Assessment and Management Table of contents Introduction... 4 Learning outcomes... 5 Section 1 Skin tears: prevention, assessment and management... 7 Section 2 What are skin tears?... 8 Section 3 Prevalence of skin tears... 9 Section 4 Age-related skin changes associated with skin tears... 10 Section 5 At-risk groups... 11 Section 6 Prevention of skin tears... 12 Learning Activity 2... 13 Learning Activity 3... 14 Section 7 Classification of skin tears... 15 Section 8 Principles for management of skin tears... 16 Learning Activity 4... 17 Learning Activity 5... 18 Learning Activity 6... 19 Section 9 When to seek help... 20 Learning Activity 7... 21 In summary... 21 Questions and answers to Learning Activities... 22 Assessment... 23 Assessment Part 1: Multiple choice... 24 Assessment Part 2: Case study to demonstrate clinical reasoning... 26 Assessment Part 1: Multiple choice answers... 28 Assessment Part 2: Case study answers... 30 Acknowledgements... 33 References... 34 3

Introduction Target audience This workbook is suitable for any practitioners and carers working in Scotland to learn about skin tears and their prevention, assessment and management. Accompanying this workbook is a video which supports the workbook and offers more in depth information including a case study on effective management of skin tears. The video can be accessed at https://vimeo.com/107907101 It is recommended that you watch the video before completing the workbook. How to use the Workbook The purpose of this workbook is to support your learning around skin tears and their prevention, assessment and management. It is a resource where you and your Line Manager/Mentor can assess your current level of knowledge of skin tears and agree your developmental needs. These should be recorded on the Statement of Completion at the end of the workbook. Completing the Workbook There are learning activities within the workbook which include: multiple choice questions questions where you can reflect on your current practice and compare it to the new recommendations for practice a case study to demonstrate clinical reasoning. The answers to the multiple choice questions can be found under Assessment Part 1: Multiple Choice Answers. You will self-mark these questions. Once you have successfully completed the learning activities your Line Manager/Mentor will review your activities and assessment answers and sign your workbook as completed, using the Statement of Completion at the end of the workbook to record your achievement. You can use the Statement of Completion to evidence achievement of the learning outcomes. NHS staff can scan and upload a copy of the Statement of Completion into e-ksf or in their own evidence of learning folder. Non NHS staff can record it in their Practice Training and Learning Record or in their own evidence of learning folder. It is estimated that it will take about 4 hours to complete the workbook. 4

Skin Tears Prevention, Assessment and Management Introduction Learning Outcomes Learning outcomes Before we move on, please take time to read the learning outcomes for this workbook. These will give you clear direction on what it covers and the learning we hope will result from it. By the end of this workbook, you will be able to: 1. Identify patient/client groups who are at risk of developing skin tears. 2. Relate age-associated skin changes to skin tears. 3. Demonstrate an understanding of skin tear prevention. 4. Categorise skin tears using the recommended assessment tool. 5. Demonstrate an understanding of best practice in assessment and management of skin tears. 5

Your details Name:... Job title:... Line Manager/Mentor:... Organisation:... Department:... Date workbook commenced:... Date workbook completed:... 6

Skin Tears Prevention, Assessment and Management Section 1 Section 1 Skin tears: prevention, assessment and management Skin tears are viewed as an increasing problem by healthcare workers and if appropriate treatment is not given, these injuries may become chronic wounds with prolonged healing - subsequently causing unnecessary pain and distress. Traditional management of skin tears can cause new damage and slow down the healing process. This type of injury usually happens in pre-term infants, newborns (infants in the first 28 days after birth) and in older people. As our population changes and the number of older people increases, whether we are caring for people in their own home, a care home or hospital, we need to be aware of best practice in prevention, assessment and management of skin tears. The image has been provided for inclusion with kind permission from the SilverChain Group 7

Section 2 What are skin tears? An international consensus panel has defined skin tears as: A wound caused by shear, friction and/or blunt force resulting in separation of skin layers. A skin tear can be partial-thickness (separation of the epidermis from the dermis) or full thickness (separation of both the epidermis and dermis from underlying structures) (LeBlanc et al 2011). They occur most commonly: at the extremes of age in critically ill or medically compromised individuals in those who require assistance with personal care Prevention of skin tears, where possible, should be our priority. When skin tears occur, accurate assessment and appropriate management will minimise further trauma and preserve viable tissue. 8

Skin Tears Prevention, Assessment and Management Sections 2 3 Section 3 Prevalence of skin tears Studies often try to determine how common a condition is in a population. This is referred to as prevalence. The studies which have been conducted to identify the prevalence of skin tears indicate that in elderly care settings, skin tears commonly occur. The evidence on prevalence and incidence of skin tears is limited and generally dated. An Australian study conducted in a long term care facility indicated that 41.5% of known wounds were found to be skin tears (Everett & Powel 1994). In 1991 an incidence of 0.92% was reported in an elderly care facility in the USA (Malone et al, 1991). A more recent survey found prevalence of between 8-11% in public hospitals in Western Australia (Government of Western Australia Department of Health, 2009). The work carried out in Australia led Carville et al (2007) to state that skin tears are perceived to be common wounds and occur more frequently than pressure ulcers. To date, there are no prevalence data available for the UK, therefore the true extent of patients requiring hospital attendance, or the resource impact or cost to the patient or the NHS due to skin tears, is still not fully known. 9

Section 4 Age-related skin changes associated with skin tears Changes to the skin due to the ageing process make the skin more vulnerable. These changes include: Thinning of the epidermis (top layer of the skin) and dermis (middle layer of the skin) Shrinkage of subcutaneous/fatty tissue (bottom layer of skin) Small blood vessel walls widen, shrink and become disorganised Decrease in collagen (natural protein component of the skin) amount and quality Reduced sebum (natural lubricant) production Pre-term and newborn infants have immature skin and are also vulnerable to skin tears. 10

Skin Tears Prevention, Assessment and Management Sections 4 5 Section 5 At-risk groups Both internal and external factors make the skin more vulnerable. The following groups have a heightened risk of skin tears: Older people The epidermis gets thinner and takes longer to repair itself The dermis gets thinner The fatty layer of the skin becomes thinner to certain areas of the body such as the face, neck, hands, arms and lower legs Pre-term infants and newborns Pre-term infants and newborns have underdeveloped skin. Furthermore, although full term infants are born with a competent skin barrier, their skin is still developing through the first year of life Learning Activity 1 Circle the one correct answer Skin tears occur most commonly: A. As a result of sport injuries B. As a result of surgery C. In critically ill and medically compromised individuals D. In school age children Those suffering from lowered immune system, malnutrition, circulation problems and poor oxygen intake People with advanced kidney disease Overweight or undernourished people People with who have had a stroke or have poor circulation in the lower legs People with heart failure 11

Section 6 Prevention of skin tears Prevention of skin tears starts with early identification of individuals who are at risk. Based on available evidence, the consensus statement of an international panel suggests certain strategies should be part of prevention. The following strategies should be considered for skin tear prevention. 1. Assess for risk upon admission to care setting and whenever the individual s condition changes and document in person centred care plan. 2. Implement a systematic prevention protocol including a person centred care plan (covered in points 3-10). 3. Have individuals at risk wear long sleeves, long trousers or knee high socks. 4. Provide limb protectors for those individuals who experience repeat skin tears. 5. Ensure safe patient handling techniques and equipment/environment. 6. Involve individuals and families in prevention strategies. 7. Educate practitioners and carers to ensure proper techniques for providing care without causing skin tears. 8. Consult dietician to ensure adequate nutrition and hydration. 9. Keep skin well lubricated by applying hypoallergenic moisturiser at least 2 times per day. Encourage the patient or their carers to apply emollient. 10. Protect individuals at high risk of trauma during routine care from self-injury, e.g. keep nails short to avoid scratching. 12

Skin Tears Prevention, Assessment and Management Section 6 Learning Activity 2 Think of an individual/person in your care with high risk of developing a skin tear. In the space provided list the strategies taken to reduce the risk to that individual and compare it to the recommendations for prevention of skin tears. Practical advice on maintaining a safe environment to minimise the risk of skin tears is also available. Where relevant, these techniques should be noted on the patient s care plan. The following should be considered to prevent skin tears. Ensure adequate lighting and position small furniture (night tables, chairs) to avoid bumps or knocks. Remove rugs and excessive furniture. Upholster or pad sharp borders of furniture or bed surroundings with padding and soft material. Use appropriate aids when transferring patients and safe patient handling techniques according to local manual handling policy. Never use bed sheets to move patients as this can contribute to damage by causing dragging effect on the skin. Always use lifting device or slide sheet. Where possible, reduce or eliminate pressure, shear and friction using pressure relieving devices and positioning techniques. 13

Learning Activity 3 Circle the one correct answer Which of the following intervention should be part of skin tear prevention? A. Have individuals at risk wear shorts sleeves, short trousers/skirts or short socks to let the skin breathe B. Assessment of the risk of skin tears if admission is greater than one month C. Keep skin well lubricated by applying skin moisturiser at least twice a day D. Use limb protectors for individuals considered at risk of skin tears 14

Skin Tears Prevention, Assessment and Management Section 7 Section 7 Classification of skin tears The most important aspect of assessment and management is to minimise further trauma and preserve viable tissue. It is important to classify the type of skin tear as this will determine the severity and aid in planning appropriate treatment. The Skin Tears Audit Research (STAR) Classification System is a validated classification tool recommended by the National Association of Tissue Viability Nurse Specialists (Scotland) for use throughout Scotland. The STAR skin tear assessment tool is outlined below. STAR Skin Tear Classification System STAR Skin Tear Classification System Guidelines 1 Control bleeding and clean the wound according to protocol. 2 Realign (if possible) any skin or flap. 3 Assess degree of tissue loss and skin or flap colour using the STAR Classification System. 4 Assess the surrounding skin condition for fragility, swelling, discolouration or bruising. 5 Assess the person, their wound and their healing environment as per protocol. 6 If skin or flap colour is pale, dusky or darkened reassess in 24-48 hours or at the first dressing change. STAR Classification System Category 1a Category 1b Category 2a Category 2b Category 3 A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened. A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened. A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened. A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened. A skin tear where the skin flap is completely absent. The image has been provided for inclusion with kind permission from the SilverChain Group 15

Section 8 Principles for management of skin tears The same principles used to manage other wounds should be employed when treating skin tears. These principles include: applying an aseptic technique controlling bleeding cleaning with sterile normal saline at body temperature applying an appropriate dressing A skin tears/first aid trauma box containing an appropriate dressing should be available in the care setting. The following are the additional recommendations for management of skin tears. Apply aseptic technique Assess the wound and the skin flap to determine the category of skin tear using a validated documentation system (e.g. STAR classification system) Cleanse the skin tear following assessment using sterile saline or water at body temperature to remove debris and any residual haematoma Depending on healthcare setting, a tetanus immunoglobulin may be administered Approximate the skin flap by gently easing the flap back into place using dampened cotton bud or gloved finger If the skin flap is difficult to align, consider applying using a sterile moistened non-woven swab for 5-10 minutes first to rehydrate the skin flap Encourage moist wound healing by applying a dressing such as soft silicone-based mesh or foam dressing, lipido-colloidal based mesh and foam dressing, calcium alginate, adsorbent clear acrylic and skin glue Avoid the use of adhesive strips. Sutures or staples are generally not recommended; however they may be required in the treatment of deep, full thickness skin tears If possible, dressing should be left in place for several days to avoid disturbing the flap If an opaque dressing is used, mark an arrow to indicate the preferred direction of removal and record in notes Dressings should be held in place with stocking-like products (e.g. tubular viscose retention bandage) Pain assessment should be carried out and appropriate analgesia should be provided Complete formal wound assessment form Document in care plan, complete accident/ incident documentation and where relevant discuss with family or next of kin 16

Skin Tears Prevention, Assessment and Management Section 8 Learning Activity 4 Think of a patient/client in your care who has developed a skin tear. In the space provided describe the care which was given and compare it to the recommendations for management. For ongoing management of skin tears, at each dressing change the dressing should be gently removed. If it does not remove easily, consider the use of saline soaks or silicone-based adhesive removers. The wound flap may be friable (fragile and bleed easily) so care should be taken to prevent disturbing it. The wound should be observed for signs of infection and any changes in the colour of the tissue of the flap that may indicate that it is becoming non-viable tissue. 17

Learning Activity 5 Look at the photographs from the STAR skin tear assessment tool on the right. From the list of categories below, write the category number of the skin tear next to each photograph. Category 1a Edges can be realigned without undue stretching. Skin flap not pale dusky or darkened. Category 1b Edges can be realigned colour is pale, dusky or darkened. Category 2a Edges cannot be realigned, colour is not pale, dusky or darkened. Category 2b Edges cannot be realigned skin is pale, darkened or dusky. Category 3 Skin flap is completely absent. 18 The images have been provided for inclusion with kind permission from the SilverChain Group

Skin Tears Prevention, Assessment and Management Section 8 Learning Activity 6 Circle the one correct answer When dressing a skin tear: A. Use adhesive strips B. Leave dressing in place for several days C. Hold dressing in place with tape D. Use products to encourage dry wound healing 19

Section 9 When to seek help If any of the following occur, you should seek help from other services. If the skin tear is extensive or associated with a full thickness injury and/or If there is uncontrolled bleeding or large haematoma formation Action: a referral to the General Practitioner if you are in the community or to surgical/plastic surgery in the hospital setting may be required. If the skin tear is on the lower leg and fails to progress over a two week period Action: consider referral to local leg ulcer clinic or vascular nurse specialist for leg ulcer assessment. If the wound fails to progress towards healing over a two week period Action: consider referral to tissue viability specialists. 20

Skin Tears Prevention, Assessment and Management Section 9 In summary Learning Activity 7 From the information you have read in this workbook how will this change the prevention and management of skin tears in your workplace? In summary Skin tears are common wounds, particularly at the extremes of age. We should be aware of the risk factors associated with skin tears and whereever possible minimise risk to patients/clients. When a patient/client develops a skin tear, the use of a skin tear classification system will aid our decision-making, and ensure we are all using the same language to describe skin tears. You have now completed the workbook. Please review your answers to the Learning Activities on the following page. Once you have done this please complete the workbook assessment. 21

Questions and answers to Learning Activities Learning Activity 1 Circle the one correct answer Skin tears occur most commonly: A. As a result of sport injuries B. As a result of surgery C. In critically ill and medically compromised individuals D. In school age children Learning Activity 5 The order the images is as follows: 2b 2a 1b 1a 3 Correct answer = C Learning Activity 3 Circle the one correct answer Which of the following intervention should be part of skin tear prevention? A. Have individuals at risk wear shorts sleeves, short trousers/skirts or short socks to let the skin breathe B. Assessment of the risk of skin tears if admission is greater than one month Learning Activity 6 Circle the one correct answer When dressing a skin tear: A. Use adhesive strips B. Leave dressing in place for several days C. Hold dressing in place with tape D. Use products to encourage dry wound healing Correct answer = B C. Keep skin well lubricated by applying skin moisturiser at least twice a day D. Use limb protectors for individuals considered at risk of skin tears Correct answer = C 22

Assessment Skin Tears Prevention, Assessment and Management Questions and answers to Learning Activities Assessment Assessment On successful completion of this assessment, learners will have demonstrated achievement of the following learning outcomes: 1. Identify patient groups who are at risk of developing skin tears. 2. Relate age-associated skin changes to skin tears. 3. Demonstrate an understanding of skin tear prevention. 4. Categorise skin tears using the recommended assessment tool. 5. Demonstrate an understanding of best practice in assessment and management of skin tear. There are 2 parts to the assessment below: Part 1: 10 multiple choice questions. 10 marks Part 2: Case study to demonstrate clinical reasoning. 10 marks The pass mark is 50% which is 10 marks in total. 23

Assessment Part 1: Multiple choice questions Choose the correct response to all the questions below by circling the ONE correct answer. Read each question, instructions and all possible answers carefully BEFORE you choose the correct answer. There are 10 questions. 1. Which of the following groups are not considered at risk of suffering from skin tears? A. Overweight patients/clients B. Elderly patients/clients C. Children D. Pre-term babies 2. Which of the following factors may not impact on fragility of the skin? A. Malnutrition B. Taking antibiotics C. Clothing worn D. Mobility 3. If individuals experience repeat skin tears on shins: A. Make sure legs are shaved to decrease the risk of infection B. Provide limb protectors C. Advise to wear short socks D. Apply moisturiser once a day 4. Which of the following practical advice can be given on maintaining a safe environment to minimise the risk of skin tears? A. Only use bed sheets to move patients B. Advise patients not to change position too much C. Encourage the use of rugs on the floor D. Ensure adequate lighting 24

Skin Tears Prevention, Assessment and Management Assessment Part 1 Assessment 5. According to the STAR skin tears classification tool, a category 1a skin tear is when the: A. Edges cannot be realigned B. Edges can be realigned and the skin or flap is pale, dusky or darkened C. Edges can be realigned and the skin or flap is not discoloured D. Skin flap is completely absent 6. According to the STAR skin tears classification tool, a category 3 skin tear is when the: A. Edges cannot be realigned B. Edges can be realigned and the skin or flap is pale, dusky or darkened C. Edges can be realigned and the skin or flap is not discoloured D. Skin flap is completely absent 7. Which of the following describes the recommended management of skin tears: A. Encourage bleeding, assess the wound, cleanse the skin, approximate the skin flap using a clean finger, apply dressing and leave for several days 8. A General Practitioner, surgical/plastic surgery referral may be required when a skin tear is: A. Associated with a superficial injury B. Associated with a full thickness injury C. Occasionally has light bleeding D. Superficial and no more than 2cms in length 9. When removing dressings for skin tears: A. Remove in the preferred direction B. Remove quickly to prevent prolonged pain C. Bleeding is a good sign that the circulation to the area is good D. Keep the area dry, even when the dressing is sticking 10. Dressings for skin tears should: A. Encourage moist wound healing B. Be held firmly with adhesive tape C. Be changed every day D. Always be clear so that you can see the wound B. Control bleeding, assess the wound, cleanse the skin, approximate the skin flap using a gloved finger, apply dressing and leave for several days C. Encourage bleeding, assess the wound, cleanse the skin, approximate the skin flap using a dry cotton bud, apply dressing and leave for several days D. Control bleeding, assess the wound, cleanse the skin, approximate the skin flap using a dry cotton bud, apply dressing and leave for several days Mark = /10 25

Assessment Part 2: Case study to demonstrate clinical reasoning Read the case study below and then list 10 factors that would be important for you, the nurse or carer, to consider when assessing this situation involving a skin tear and deciding upon appropriate management. Case study Mrs Cook is a patient/client in your care home. She has cut her leg after bumping into a coffee table. Mrs Cook is 75 years old, has rheumatoid arthritis and needs help with mobility. Mrs Cook doesn t eat well and her daughter, who visits twice a week, is worried about this. Relevant factors: 1. 2. 3. 4. 5. 6. If, after working on the answer to this question for at least 10 minutes, you cannot list 10 relevant factors; you may consult with peers or receive prompts from your line manager/mentor until you have identified at least 10 relevant factors. 7. 8. 9. 10. Mark = /10 26 Total mark combining multiple choice questions mark and case study mark = /20

Skin Tears Prevention, Assessment and Management Assessment Part 2 Assessment You have now completed the assessment. Please check your answers against those provided on the following page and mark your assessment. Following this, meet with your Line Manager/Mentor and discuss your current level of knowledge and any development needs you may have. 27

Assessment Part 1: Multiple choice answers Check your answers against the answers below. Allocate one mark for each correct answer. If your answer is incorrect, revisit the section of the workbook indicated below with the correct answer. 1. Which of the following groups are not considered at risk of suffering from skin tears? A. Overweight patients/clients B. Elderly patients/clients C. Children D. Pre-term babies Correct answer = C Workbook Section 5 2. Which of the following factors may not impact on fragility of the skin? A. Malnutrition B. Taking antibiotics C. Clothing worn D. Mobility Correct answer = B Workbook Section 6 3. If individuals experience repeat skin tears on shins: A. Make sure legs are shaved to decrease the risk of infection B. Provide limb protectors C. Advise to wear short socks D. Apply moisturiser once a day Correct answer = B Workbook Section 6 4. Which of the following practical advice can be given on maintaining a safe environment to minimise the risk of skin tears? A. Only use bed sheets to move patient B. Advise patients not to change position too much C. Encourage the use of rugs on the floor D. Ensure adequate lighting Correct answer = D Workbook Section 6 5. According to the STAR skin tears classification tool, a category 1a skin tear is when the: A. Edges cannot be realigned B. Edges can be realigned and the skin or flap is pale, dusky or darkened C. Edges can be realigned and the skin or flap is not discoloured D. Skin flap is completely absent 28 Correct answer = C Workbook Section 7

Skin Tears Prevention, Assessment and Management Assessment Part 1 answers Assessment 6. According to the STAR skin tears classification tool, a category 3 skin tear is when the: A. Edges cannot be realigned B. Edges can be realigned and the skin or flap is pale, dusky or darkened C. Edges can be realigned and the skin or flap is not discoloured D. Skin flap is completely absent Correct answer = D Workbook Section 7 8. A General Practitioner, surgical/plastic surgery referral may be required when a skin tear is: A. Associated with a superficial injury B. Associated with a full thickness injury C. Occasionally has light bleeding D. Superficial and no more than 2cms in length Correct answer = B Workbook Section 9 7. Which of the following describes the recommended management of skin tears: A. Encourage bleeding, assess the wound, cleanse the skin, approximate the skin flap using a clean finger, apply dressing and leave for several days B. Control bleeding, assess the wound, cleanse the skin, approximate the skin flap using a gloved finger, apply dressing and leave for several days C. Encourage bleeding, assess the wound, cleanse the skin, approximate the skin flap using a dry cotton bud, apply dressing and leave for several days D. Control bleeding, assess the wound, cleanse the skin, approximate the skin flap using a dry cotton bud, apply dressing and leave for several days Correct answer = B Workbook Section 8 9. When removing dressings for skin tears: A. Remove in the preferred direction B. Remove quickly to prevent prolonged pain C. Bleeding is a good sign that the circulation to the area is good D. Keep the area dry, even when the dressing is sticking Correct answer = A Workbook Section 8 10. Dressings for skin tears should: A. Encourage moist wound healing B. Be held firmly with adhesive tape C. Be changed every day D. Always be clear so that you can see the wound Correct answer = A Workbook Section 8 29

Assessment Part 2: Case study answers Read the case study below and then list 10 factors that would be important for you, the nurse or carer, to consider when assessing this situation involving a skin tear and deciding upon appropriate management. Case study Correct answer: 10 factors to be identified 1. 2. Role of family/carers Type of clothes worn Mrs Cook is a patient/client in your care home. She has cut her leg after bumping into a coffee table. Mrs Cook is 75 years old, has rheumatoid arthritis and needs help with mobility. Mrs Cook doesn t eat well and her daughter, who visits twice a week, is worried about this. 3. 4. 5. 6. Nutrition Age Circulation Cause of the skin tear 7. Pain level 8. Eyesight 9. Other medical conditions 10. Ability to self care If you were unable to identify any of the factors please review the table on page 31 which identifies the reasons why these factors are relevant and revisit Sections 5, 6 and 8 of your workbook. 30

Skin Tears Prevention, Assessment and Management Assessment Part 2 answers Assessment Guideline answer: Relevant factors Role of family/carers Nutrition Circulation Pain level Other medical conditions Type of clothes worn Age Cause of the skin tear Eyesight Ability to self-care Reasons for relevance Carers may need to be educated about the importance of good skin care Carers may need information about risk factors Carers may need information about the management plan Impact on condition of the skin Impact on healing Impact on energy levels/ability to self-care Impact on condition of the skin Impact on skin sensation/awareness May give an indication of the depth of the tear May give an indication of sensory levels Pain must be managed Impact on mobility Impact on circulation, skin condition Possible impact on communication Skin may not be covered during moving and handling procedures Skin more prone to tearing due to age-related changes Other age-related changes may increase risk (for example hearing loss may have an impact on communication with carers) Has to be identified to prevent further occurrence Has to be identified to inform management (e.g. safe moving and handling as part of the management plan) May affect ability to transfer safely May affect ability to read any written instructions about a dressing etc. Moving and handling may be a risk that needs to be managed May not be moving safely in bed May affect ability to keep dressing clean 31

Statement of completion of the Skin Tears prevention, assessment and management workbook Name of Organisation:... Name of person who completed the learning outcomes and 4 hours learning time:... Job title:... Ward/Unit/Department:... Date of completion:... Signature of Line Manager/Mentor:... Pass mark of...% obtained: Agreed development needs:......... 32

Skin Tears Prevention, Assessment and Management Statement of Completion Acknowledgements Acknowledgements NHS Education for Scotland would like to acknowledge the support they received from the National Association of Tissue Viability Nurse Specialists (Scotland) and the Wound Care Advisory Group in the development of this workbook. Thanks are also given to Dr Sabine Nolte, Educational Projects Manager, NHS Education for Scotland for her invaluable advice and contribution to the resource development. Membership of the Wound Care Advisory Group Sarah Freeman Educational Projects Manager (Chair) NHS Education for Scotland Janice Bianchi JB Medical Ed Ltd Honorary Lecturer Glasgow University Alison Edwardson Senior Infection Control Manager NHS Greater Glasgow & Clyde Mary Hutchinson Staff Nurse NHS Ayrshire & Arran Liz McMath Tissue Viability Nurse NHS Ayrshire & Arran Joyce O Hare Professional Adviser Tissue Viability Care Inspectorate Linda Primmer Tissue Viability Nurse NHS Lothian and Chair of National Association of Specialist Tissue Viability Nurses (Scotland) Anne Wilson Tissue Viability Nurse NHS Greater Glasgow & Clyde Adam Wood Senior Infection Control Nurse NHS Borders 33

References Carville K, Lewin G, Newall N et al (2007) STAR: a consensus for skin tear classification. Primary Intention 15:1:18-28 Everett S, Powel T (1994) Skin tears the underestimated wound. Prim Intent 2; 8:8-30 LeBlanc K, Baranoski (2011) Skin Tears: State of Science Consensus statement of the prevention, prediction, assessment and treatment of skin tears. Advances in Skin and Wound Care 24; 9:2-15 Malone ML, Rozario N, Gavinski M, Goodwin J (1991) The epidemiology of skin tears in the institutionalised elderly. Journal of American Geriatric Society 39; 6:591-595 National Association of Tissue Viability Nurses Scotland (2009), Prevention and Management of Pressure Ulcers Best Practice Statement WoundsWest wound survey 2009: Key results at a glance. Government of Western Australia Department of Health 34

This resource may be made available in full, or in summary form, in alternative formats and community languages. Please contact us on 0131 656 3200 or e-mail altformats@nes.scot.nhs.uk to discuss how we can best meet your requirements. NHS Education for Scotland 102 Westport Edinburgh EH3 9DN www.nes.scot.nhs.uk Published September 2015